How often had you heard that “every other developed country has single-payer health insurance”? So often that I have lost count. How often have you heard that those single-payer health systems provide superior health care at lower costs? Again, so often that I have lost count.
Yet when you actually start to dig around, you discover that there is a wide range of health care systems in other developed countries — and many of them are not single-payer at all, at least in the way that Britain or Canada is.
Singapore, for example, has a mandatory savings system called Medisave, similar in purpose to the Health Savings Accounts that Americans are encouraged (but not required) to open. And while the Singapore government does pay for basic health care, it also allows patients to spend their own money to upgrade their hospital rooms. It also offers optional catastrophic health insurance. Not American-style, but definitely not single-payer.
Singapore also works aggressively to control behavior-related medical costs in a way that would lead to hyperventilating lawsuits in America. Homosexual sex is still an imprisonable crime in Singapore — hence, relatively low AIDS rates. Singapore is also the world’s top executioner, at least partly because various drug dealing charges carry the death penalty.
It’s a pretty controlling place — they only recently legalized chewing gum. I suppose if we were prepared to exercise that level of control over our population, we could also get our health care costs down.
Germany is another country often touted by the single-payer advocates, but it isn’t single-payer, either. About 92 percent of the country has health insurance that private employers are required to provide, with peculiarly enough, civil servants and the self-employed using private health insurance (which is apparently mandatory). Surprisingly, 0.3 percent of the German population is not insured at all: either the very rich and those so poor that the government directly provides health care.
What about health outcomes? It is very easy to assume that America is typical of developed nations, and thus our high mortality rates must be because we lack single-payer health insurance. We really aren’t demographically typical — some of those differences are genetic and some are behavioral.
Obesity is a major factor in determining mortality in morbidity rates, and Americans are more likely to be obese than people in other developed countries (although Britain is catching up fast). For example, 33 percent of American women are obese, compared to 19 percent of Canadian women. Is this cultural or genetic?
It may be both. In the U.S., 35.7 percent of blacks are obese, compared to 23.7 percent of non-Hispanic whites and 28.7 percent of Hispanics.
One of the figures that gets a lot of attention from the “single-payer solves everything” crowd is infant mortality rates. Canada, indeed, has a lower infant mortality rate than the U.S. Our rates are indeed a scandal — but maybe not because of our health care system.
A big chunk of our problem in this area is that black infant mortality rates are more than double the white rate. Maybe that’s because we have a lousy health care system and blacks are getting inferior health care (and America has a large black population, unlike Canada and most other developed nations). But Canada isn’t much better on this — ranking 16th out of 17 peer nations on infant mortality.
Adding to the problem of international comparisons is that we aren’t all measuring infant mortality the same way:
A European report on perinatal indicators, for example, noted a wide variation in how European countries define infant mortality, due to differences in birth and death registration practices (that is, differences in the cut-off points for acceptable weight or estimated gestation period to be registered as a birth and subsequent death).
In short, it appears that the U.S. and Canada may both look bad compared to other developed countries because we’re more accurate in how we record infant mortality.
Finally, our infant mortality rate is indicative of behavioral problems that are unrelated to health care. Infant mortality rates are strongly correlated with low birth weight, which, in turn, is caused by smoking and substance abuse — an area where the U.S. is, unfortunately, well ahead of other nations, including Canada.
Perhaps the most startling study is one published in 1999 by a research organization funded by the Ontario Ministry of Health and Canada Public Health Agency: “Health Care Delivery in Canada and The United States: Are There Relevant Differences in Health Care Outcomes?” They concluded that there were definitely differences in particular areas of health care. In some cases, Canada did better; in others, the United States did better (for example, American heart attack victims were more likely to enjoy “increased functional status” than their Canadian counterparts). But overall, they concluded that there wasn’t a significant difference in health care outcomes and acknowledged that demographics might be a part of the mortality differences.
I’m not happy with our current health care system, and I have previously explained some of my proposals to improve coverage for the uninsured. But I’m even less happy with the way in which advocates of single-payer falsely portray hybrid systems as “single-payer” and the differences in health care outcomes as entirely the result of differences in the health care system.